Li et al.

BMC Oral Health (2023) 23:333 BMC Oral Health

https://doi.org/10.1186/s12903-023-03015-w

RESEARCH Open Access

Longitudinal association of edentulism

with cognitive impairment, sarcopenia and all-
cause mortality among older Chinese adults
Yang Li1†, Chuan-Long Huang1†, Xiu-Zhen LU1, Zi-Qing Tang1, Yuan-Yin Wang1, Ying Sun1,2* and Xin Chen1*

Abstract
Background Tooth loss may be a surrogate for systemic health and aging. However, no previous studies have
systematically assessed multiple outcomes relevant to aging trajectory in this area, and many important confounders
were not adjusted in most previous studies. This study aims to prospectively evaluate the associations of complete
tooth loss (edentulism) with broad markers of sarcopenia, cognitive impairment and mortality.
Methods Data were derived from the China Health and Retirement Longitudinal Study, a nationally representative
household study of the Chinese population aged 45 years and older. Multivariate Weibull proportional hazards
regression was used to assess the association between edentulism with sarcopenia and all-cause mortality. Average
changes in cognitive function by edentulism was estimated by mixed-effects linear regression models.
Results During the 5-year follow-up, the prevalence of edentulism among adults aged 45 and over was 15.4%.
Participants with edentulism had a greater decline in cognitive function compared to those without (β=-0.70, 95%CI:-
1.09, -0.31, P < 0.001). The association of edentulism and all-cause mortality for 45–64 age group (HR = 7.50, 95%CI:
1.99, 28.23, P = 0.003), but not statistically significant for the ≥ 65 age group (HR = 2.37, 95%CI: 0.97, 5.80, P = 0.057).
Effects of edentulism on sarcopenia are statistically significant for all age groups (45–64 age group: HR = 2.15, 95%CI:
1.27, 3.66, P = 0.005; ≥65 age group: HR = 2.15, 95%CI: 1.27, 3.66, P = 0.002).
Conclusions These findings could have important clinical and public health implications, as tooth loss is a quick and
reproducible measurement that could be used in clinical practice for identifying persons at risk of accelerated aging
and shortened longevity, and who may benefit most from intervention if causality is established.
Keywords Cognitive impairment, Edentulism, Longitudinal analysis, Mortality, Sarcopenia

†
Yang Li and Chuan-Long Huang authors contribute equally.
*Correspondence:
Ying Sun
yingsun@ahmu.edu.cn
Xin Chen
chenxinkq2672@126.com
1
Key Laboratory of Oral Diseases Research of Anhui Province,
Stomatologic Hospital & College, Anhui Medical University, Hefei, China
2
Department of Maternal, Child & Adolescent Health, School of Public
Health, Anhui Medical University, 81th Meishan Road, Hefei,
Anhui Province 230032, China

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Li et al. BMC Oral Health (2023) 23:333
Background
China has one of the fastest growing ageing populations
in the world. The latest results of China’s seventh popu-
lation census show that in 2020, China’s population was
1.411 billion, of which 264 million were 60 years old
and over, and 191 million were 65 years old and over,
accounting for 18.7% and 13.5% of the total population
respectively [1]. Comparing with the previous intercensal
period, population aging in China accelerated in the last
decade, which poses a major challenge to the health care
system to ensure the health and longevity of an aging
society. Oral health is an important intrinsic component
of human health and well-being; however, oral health
has been neglected in the current global health agenda.
With the continuous progress of medical treatment and
the massive investment of public health resources, most
oral diseases can be prevented and cured, however, due
to the irreversible aging and incomplete health protec-
tion measures, the elderly often do not receive necessary
daily oral care, so it is impossible to maintain a good oral
health level and oral hygiene status in old age. In addi-
tion to periodontal disease, there are a number of other
oral diseases and functional problems that are common
among the elderly, including edentulousness. Edentu-
lism and severe tooth loss are still a major burden of oral
disease disability worldwide [2]. Globally, about 30% of
adults aged 65–74 have lost all of their teeth [3]. In view
of the low utilization rate of oral health care for Chinese
adults [4], it is speculated that the prevalence of edentu-
lism in the elderly in China may be higher.
Friedman & Lamster [5] proposed that tooth loss may
be a surrogate for systemic health and aging. Previous
studies have reported lower rates of tooth loss among
centenarians than younger members of the birth cohort
aged 65–74 years [6]. Positive correlations between eden-
tulism with cognitive impairment [7, 8], chronic illness
[9, 10], depression [11], as well as cancer [12] are emerg-
ing in the literature. One recent research review reported
that unrecovered patients with stage IV periodontitis
showed lower cognitive status, higher drug intake and
frailty [13]. Studies are needed to clarify the relationship
between edentulism and tooth loss with the components
of the frailty phenotype, e.g. low grip strength, slow gait
speed and low physical activity [14].
Whilst reviewing the adverse effects of edentulism,
no previous studies have systematically assessed mul-
tiple outcomes relevant to aging trajectory in this area,
and many important confounders were not adjusted in
most previous studies. Furthermore, primary evidence
largely comes from high-income countries, whereas in
low- and middle-income countries, this association has
been underexplored. The present study seeks to prospec-
tively evaluate the associations of complete tooth loss
(edentulism) with broad markers of sarcopenia, cognitive
Page 2 of 10
impairment and mortality, in community-dwelling older
adults participating in the China Health and Retirement
Longitudinal Study (CHARLS).
Methods
Study population and design
This study analyzed a nationally representative data from
the China Health and Retirement Longitudinal Study
(CHARLS), which covered 450 villages or communities
in 150 counties or districts of 28 provinces in China and
was conducted among 45 years and older population. The
baseline survey was conducted in 2011 (Wave 1, W1),
through a four-stage, stratified, cluster probability sam-
pling design. Considering the availability of complete
tooth loss data, this study utilized data from the wave 2
in 2013 and two follow up surveys (wave 3, 2015; wave
4, 2018). Further details are provided elsewhere [15]. The
exclusion criteria were as follows: (i) those individuals
who did not report an edentulous status; (ii) age was less
than 45 years old; and (iii) those with missing data. The
CHARLS study was approved by the Biomedical Ethics
Review Committee of Peking University (approval num-
ber IRB00001052–11,015). All interviewees provided
informed consent. The research has been performed in
accordance with the Declaration of Helsinki. The data is
available freely at http://charls.pku.edu.cn/. This study
included 19,157 participants with information on com-
plete tooth loss at Wave 2 (Fig. 1).
Measurements
Edentulism
Information on complete tooth loss was assessed in Wave
2 to Wave 4, through one question: “Have you lost all of
your tooth?”, the variable had two options (yes or no).
Cognitive function
Cognitive function was measured from two dimensions
[16], the first dimension is episodic memory divided
into immediate word recall (0–10 point) and delayed
word recall (0–10 point), asking respondents to repeat,
regardless of the order, 10 Chinese nouns immediately
and 5 min later. The second dimension was mental status
based on questions of the Telephone Interview of Cog-
nitive Status (TICS) battery, which established to under-
stand the integrity or mental state of the individual [17].
Mental status was measured from orientation, visuo-con-
struction, and attention. CHARLS examined orientation
through the respondents’ recognition of date (month,
day, year), and the day of the week (0–4 points). Visuo-
construction (0–1 point) was assessed by asking individ-
uals to exactly redraw a picture of overlapping pentagons
on the paper. Attention (0–5 points) was measured by
serial subtraction of 7 from 100 for five times. The total
Li et al. BMC Oral Health (2023) 23:333
Fig. 1 Study flowchart
cognitive function score varied from 0 to 30, with higher
values meaning better cognitive function [18].
Assessment of sarcopenia
According to the AWGS criteria, sarcopenia was diag-
nosed if participants had low muscle mass plus low mus-
cle strength or low physical performance [19].
Measurement of muscle strength AWGS 2019 recom-
mends using handgrip strength to indicate skeletal mus-
cle strength. Handgrip strength (kg) was measured in the
dominant hand and non-dominant hand, with the par-
ticipant squeezing a YuejianTM WL-1000 dynamometer
(Nantong Yuejian Physical Measure-ment Instrument
Co., Ltd., Nantong, China) as hard as possible. According
Page 3 of 10
to the suggestion of AWGS 2019, the cut-off points for
low handgrip strength are < 18 kg in women and < 28 kg
in men.
Measurement of muscle mass The muscle mass was esti-
mated by the appendicular skeletal muscle mass (ASM)
using a previously validated anthropometric equation in a
Chinese population [20]:
0.193*weight + 0.107*height - 4.156*sex1 -
(1)
0.037*death_age - 2.631
The height, body weight and age were measured in cen-
timeters, kilograms and years, respectively. For sex, the
value 1 represented men, and the value 2 represented
Li et al. BMC Oral Health (2023) 23:333
women. The agreement of the ASM equation model
and dual X-ray absorptiometry (DXA) was strong. After
calculating the ASM, the height-adjusted muscle mass
(ASM/Ht2) was calculated using the ASM divided by
the square of the height in meters. The ASM/Ht2 val-
ues of < 5.63 kg/m2 in women and < 7.05 kg/m2 in men
were considered as low muscle mass. In terms of physi-
cal performance, the gait speed and the chair stand test
were performed using the method described by Wu et al.
[21]0.10 Further details about the definitions for sarco-
penia components in the CHARLS have been described
previously.10 According to AWGS 2019, the criteria for
low physical performance are 6-m walk < 1.0 m/s, or
5-time chair stand test ≥ 12 s [19].
All-cause mortality
The death information in CHARLS was determined by
the exit interview status (alive or dead) of participants in
Waves 3 and Wave 4. Considering the exact time of death
was not recorded, the median of the two follow-up times
was used as the survival time.
Covariates
We selected covariates that may confound the relation-
ship based on a review of literature. The selected covari-
ates should have an impact on the physical fragility,
cognitive impairment, and overall mortality and been
collected in the CHARLS. Because the sample size of this
study is large and statistical power is strong, we included
as many covariates as possible to minimize the poten-
tial confounding effect. The covariates for our analyses
included sociodemographic characteristics (age, sex,
household income, education, occupation status, marital
status and residence), routine physical checkup (weigh,
height, and blood pressure), lifestyle behaviors (smok-
ing, alcohol drinking and sleep duration), self-reported
chronic conditions (hypertension, diabetes/hyperglycae-
mia, cancer, lung disease, stroke, heart disease, psycho-
logical disease, arthritis, liver disease, kidney disease,
digestive disease, asthma and memory-related disease).
Details on the precision of the covariates are provided in
the appendix.
Statistical analyses
Baseline characteristics of participant with and without
edentulism were compared using χ2 tests for categorical
measures and t tests for continuous measures. Statistical
analysis was performed from April to August, 2022. Aver-
age changes in cognitive function over Wave 2 to Wave 4
by edentulism status was estimated using mixed-effects
linear regression models. We ran three incremental mod-
els: Model 1 was adjusted for sociodemographic fac-
tors (age, sex, household annual income and education);
Model 2 was additionally adjusted for health-related
Page 4 of 10
factors including smoking, drinking, activities of daily
living, sleep duration and body mass index; and Model 3
was additionally adjusted for self-reported medical his-
tory (hypertension, diabetes, respiratory illnesses, stroke
and heart disease and other chronic illnesses at Wave 4).
Sensitivity analysis was conducted in subgroups of pop-
ulation without stroke or heart diseases to examine the
stability of results.
Multivariate Weibull proportional hazards regression
model before and after adjusting for confounding factors
(sociodemographic factors, health-related factors, and
self-reported medical history) were used to estimate the
associations between edentulism with all-cause mortality
and sarcopenia. Hazard ratios (HRs) and 95% CIs were
reported for both unadjusted and covariate-adjusted
models. Statistical significance was set at two-sided
P < 0.05. Analyses were performed using STATA v15 sta-
tistical software.
Results
The characteristics of study participants according to
edentulous groups are presented in Table 1. The mean
age of the 16 501 participants was 58.8 (standard devia-
tion [SD], 9.5) years, and 51.2% were women. Nearly 2/3
(66.4%) of participants received primary education or
less.
The prevalence of edentulism among adults aged 45
and over was 15.4% (2537/16,501), with 10.1% for age
group 45–64 years, 25.6% for age group 65–74 years
and 44.2% for age group 75 and over. Compared to those
without edentulism, edentulous participants were older,
being female, less educated, and had lower BMI, lower
household income, and lower alcohol use (all Ps < 0.001).
As shown in Table 1, compared to those without eden-
tulism, the prevalence of high blood pressure at 2013
wave was significantly higher among participants with
edentulism (P < 0.001). The prevalence of heart diseases
was similar at 2013 between the two groups (14.1% vs.
13.2%, P = 0.257), but significantly increased at 2015
(20.2% vs. 17.6%, P = 0.004) and 2018 (25.1% vs. 21.1%,
P < 0.001) among elder population with edentulism.
Cognitive function score declined with age during the
follow-up period in all participants (Table 2). Partici-
pants with edentulism had a greater decline compared
to those without. The associations remained significant
after adjusted prevalent cardiovascular diseases, e.g.
high blood pressure, diabetes, stroke and heart disease
at Wave 4 (β=-0.70, 95%CI:-1.09, -0.31, P < 0.001). Results
from sensitivity analyses excluding participants with
baseline cardiovascular diseases were qualitatively simi-
lar (β=-0.68, 95%CI: -1.10, -0.26, P = 0.001).
Table 3 shows the associations between edentulism
with mortality and sarcopenia from the random-inter-
cept Weibull hazard models, respectively. The mortality
Li et al. BMC Oral Health (2023) 23:333 Page 5 of 10

Table 1 Characteristics of study participants by edentulism at 2013 in China Health and Retirement Longitudinal Study
Characteristics Total sample Edentulism during 2013–2018 P-values
(n = 16,501)
Yes (n = 2537) No (n = 13,964)
Age at 2013 (years), mean (SD) 16,501 65.5 ± 9.9 57.6 ± 8.8 < 0.001
45–64 years 12,271 1244 (10.1) 11,027 (89.9) < 0.001
65–74 years 3104 795 (25.6) 2309 (74.4)
>=75 years 1126 498 (44.2) 628 (55.8)
Female, n (%) 0.001
Female 8449 1374 (16.3) 7075 (83.7)
Male 8052 1163 (14.4) 6889 (85.6)
Education at 2013, n (%) 14,403 < 0.001
Primary or less 9570 1781 (18.6) 7789 (81.4)
Lower secondary 3123 314 (10.1) 2809 (89.9)
Upper secondary & vocational 1500 99 (6.6) 1401 (93.4)
Tertiary 210 16 (7.6) 194 (92.4)
Household income at 2013, mean (SD) 9377 10376.7 ± 12498.0 18941.3 ± 24766.4 < 0.001
BMI at 2013, mean (SD) 10,145 23.1 ± 5.2 24.1 ± 3.7 < 0.001
Current smoke at 2013, n (%) 13,943 520 (25.4) 3215 (27.0) 0.145
Alcohol use at 2013, n (%) 13,943 565 (27.6) 4055 (34.1) < 0.001
High blood pressure at 2013, n (%) 13,277 580 (26.4) 2434 (22.0) < 0.001
Dentures, n(%) 14,303 516 (61.8) 4020 (29.8) < 0.001
Stroke, n (%)
W2 (2013) 13,253 72 (3.3) 304 (2.8) 0.181
W3 (2015) 13,810 95 (4.5) 450 (3.8) 0.150
W4 (2018) 13,963 192 (9.4) 932 (7.8) 0.019
Heart diseases, n (%)
W2 (2013) 13,218 310 (14.1) 1451 (13.2) 0.257
W3 (2015) 13,719 425 (20.2) 2044 (17.6) 0.004
W4 (2018) 13,961 514 (25.1) 2516 (21.1) < 0.001
Global cognition score, mean (SD)
W2 (2013) 10,286 13.9 ± 4.9 15.5 ± 4.6 < 0.001
W3 (2015) 11,294 13.1 ± 4.8 14.9 ± 4.7 < 0.001
W4 (2018) 8575 13.8 ± 5.2 15.7 ± 5.0 < 0.001
Sarcopenia at 2015, n (%) 7666 131 (11.3) 242 (3.7) < 0.001
Death at 2018, n (%) 16,256 217 (9.5) 496 (3.6) < 0.001

incidence rate among older adults with edentulism was
19.9 per 1000 person-years (95%CI: 17.4, 22.7), compared
to 8.1 per 1000 person-years (95%CI: 7.4, 8.8) among
control group. Similarly, the incidence of sarcopenia dur-
ing 2013 to 2015 waves was significantly higher in eden-
tulous participants (28.3 cases per 1000 person years,
95%CI: 22.8, 35.1) compared to their counterparts from
control group (10.4 cases per 1000 person years, 95%CI:
9.3, 11.7).
We calculated two regression models—the null model
is an empty model without any covariates, and the full
model includes all covariate—gender, educational level,
BMI, baseline cardiovascular diseases, diabetes, respi-
ratory illnesses and other chronic morbidities, physi-
cal activity, current smoking and drinking behavior, and
household income. In both models, the variation in mor-
tality and sarcopenia risk was statistically significant. The
median hazard of mortality and sarcopenia is 2.88- and
1.70-times higher among edentulous participants, com-
pared with control groups (mortality: 95%CI: 1.39,
5.98, P = 0.004; sarcopenia: 95%CI: 1.32, 2.20, P < 0.001)
(Table 3; Fig. 2).
We age-stratify our analysis by separately examining
each of the two age groups, 45–64 years and 65 years or
older. The results confirm the association of edentulism
and all-cause mortality for 45–64 age group (HR = 7.50,
95%CI: 1.99, 28.23, P = 0.003), but not statistically signifi-
cant for the ≥ 65 age group (HR = 2.37, 95%CI: 0.97, 5.80,
P = 0.057). Effects of edentulism on sarcopenia are sta-
tistically significant for all age groups (45–64 age group:
HR = 2.15, 95%CI: 1.27, 3.66, P = 0.005; ≥65 age group:
HR = 2.15, 95%CI: 1.27, 3.66, P = 0.002).
Li et al. BMC Oral Health (2023) 23:333 Page 6 of 10

Table 2 Average changes in cognitive function during 2013 to 2018 waves by edentulism in CHARLS using mixed-effects linear
regression models
Variables β-coefficient (95% confidence) Interval),
cognitive function during Wave 2 to Wave
4
Model 1 a Model 2 a Model 3 a
Total sample
Edentulism
No Reference Reference Reference
Yes -0.50 (-68, -0.33) ¶ -0.75 (-1.13, -0.70 (-1.09,
-0.38) ¶ -0.31) ¶
Age -0.11 (-0.12, -0.12 (-0.14, -0.12 (-0.14,
-0.10) ¶ -0.11) ¶ -0.11) ¶
Female -0.53 (-0.65, 0.42) ¶ -1.02 (-1.31, -1.00 (-1.31,
-0.74) ¶ -0.70) ¶
Education
Primary or less Reference Reference Reference
Lower secondary 2.92 (2.78, 3.06) ¶ 3.04 (2.74, 3.15 (2.84,
3.35) ¶ 3.47) ¶
Upper secondary 4.41 (4.23, 4.59) ¶ 4.50 (4.05, 4.64 (4.17,
4.94) ¶ 5.11) ¶
Tertiary 5.79 (5.38, 6.21) ¶ 6.27 (4.99, 6.31 (4.89,
7.54) ¶ 7.73) ¶
Participants without stroke or heart diseases at Wave 2
Edentulism
No Reference Reference Reference
Yes -0.56 (-0.89, -0.70 (-1.12, -0.68 (-1.10,
-0.23) § -0.28) § -0.26) §
a
Model 1 was adjusted for age, sex, household annual income and education; Model 2 was further adjusted for smoking, alcohol drinking, sleep duration, body mass
index and dentures; in Model 3, hypertension, diabetes, respiratory illnesses, stroke and heart disease and other chronic illnesses at Wave 4 were added

Discussion attributed to differences in the age range and ethnicity of

Based on the nationally representative CHARLS cohort,
we found that edentulism was related to subsequent
cognitive impairment, risk for sarcopenia and all-cause
mortality among 16,501 elderly population in China.
Moreover, all the association between complete tooth
loss and these aging relevant outcomes remained highly
significant in the competing risk model with fully multi-
variable analysis. As far as we know, this is the primary
prospective study to assess cumulative edentulism while
studying associations with subsequent cognitive impair-
ment, risk of sarcopenia and all-cause mortality.
Using a prospective design, our results show robust
evidence of an association of lower education and house-
hold income with incident edentulism among Chinese
adults aged 45 and above. These findings were consistent
with previous studies [22, 23], and highlighted the impor-
tance of addressing “upstream” determinants of oral
health, especially for the most vulnerable populations in
order to ensure compliance with the principle of equity
[24].
A growing number of epidemiological studies focused
on the effect of oral health on cognitive function [25, 26],
however, less studies paid attention to edentulism and
with mixed findings [8, 21, 27]. The inconformity may be
the subjects, as well as differences in the measures and
methods of cognitive function and oral health. Our find-
ings are consistent with Lu et al. [8], demonstrating that
the relationship between edentulism and lower level of
episodic memory and psychological integrity at follow-
up among Chinese elder population.
Certain physiological mechanisms could link edentu-
lism to poor cognitive function. A recent animal study
observed that tooth loss in the juvenile Sprague–Daw-
ley rats will reduce the number of pyramidal neurons in
the hippocampus, inhibit the expression of BDNF, TrkB,
AKT1, and NR2B, and eventually lead to cognitive dys-
function [28]. Other potential explanations include the
long-term inflammatory stress pathway, which involves
metabolic disorders, microbial-gut-brain axis, the acti-
vation of microglia and astrocytes, and inflammatory
cascade effect in central nervous system [29]. Thus, our
study generated important scientific evidence for early
detection of cognitive impairment and dementia. Finally,
the non-significant associations in the middle-aged group
may have resulted from the fact that this group was still
relatively young and might not have experienced a signifi-
cant decline in cognitive function during the 5-year study
period.
Li et al. BMC Oral Health (2023) 23:333 Page 7 of 10

Table 3 Association of edentulism with mortality and sarcopenia estimated by random-intercept Weibull hazard models
Cases Incidence Rate (95%CI), per Hazard Ratio / Odds Ratio a
1000 Person-Years Model 1 Model 2
Incidence of death at Wave 4
Total
No edentulism group 496 8.1 (7.4, 8.8) Reference Reference
Edentulism group 217 19.9 (17.4, 22.7) 2.52 (2.15, 2.95) ¶ 2.88 (1.39, 5.98) §
Female 502 11.8 (10.8, 12.9) 0.32 (0.12, 0.81) *
Education
Primary or less 687 12.8 (11.9, 13.8) - Reference
Lower secondary 127 7.4 (6.2, 8.8) - 0.51 (0.15, 1,74)
Upper secondary and higher 52 5.5 (4.2, 7.2) - 0.80 (0.17, 3.69)
Aged 45–64
No edentulism group 199 4.2 (3.6, 4.8) Reference Reference
Edentulism group 34 6.2 (4.4, 8.6) 2.52 (2.15, 2.95) ¶ 7.50 (1.99, 28.23) §
Aged 65 or older
No edentulism group 297 19.4 (3.6, 24.4) Reference Reference
Edentulism group 183 33.8 (29.3, 39.1) 1.59 (1.32, 1.91) ¶ 2.37 (0.97, 5.80)
Incidence of sarcopenia at Wave 3
Total
No edentulism group 291 10.4 (9.3, 11.7) Reference Reference
Edentulism group 82 28.3 (22.8, 35.1) 3.37 (2.72, 4.17) ¶ 1.70 (1.32, 2.20) ¶
Female 287 16.7 (14.8, 18.7) 1.04 (0.77, 1.42)
Education
Primary or less 442 21.2 (19.3, 23.2) - Reference
Lower secondary 37 5.6 (4.0, 7.7) - 0.43 (0.25, 0.75) §
Upper secondary and higher 14 3.9 (2.3, 6.6) - 0.46 (0.21, 1.04)
Aged 45–64
No edentulism group 74 3.9 (3.1, 4.9) Reference Reference
Edentulism group 23 10.6 (7.1, 16.0) 3.22 (2.01, 5.16) ¶ 2.15 (1.27, 3.66) §
Aged 65 or older
No edentulism group 168 30.3 (26.1, 35.2) Reference Reference
Edentulism group 108 49.8 (41.2, 60.1) 1.65 (1.30, 2.11) ¶ 1.58 (1.19, 2.09) §
a
Model 1 was unadjusted for covariates; Model 2 was adjusted for age, sex, education, household annual income, smoking, alcohol drinking, sleep duration,
dentures, body mass index, hypertension, diabetes, respiratory illnesses, stroke and heart disease and other chronic illnesses at Wave 4

Several previous studies have evaluated whether
edentulism and partial edentulism may be predictive of
shortened longevity [30–34], mostly conducted in high-
and upper-middle-income countries, which revealed
small association. Our study has further extended such
associations, indicating that late middle-aged adults
(45–64 yeas) with edentulism presented a substantially
(7.5-times) higher risk for all-cause mortality than the
reference population, while edentulous elder popula-
tion over 65 years of age demonstrated no extra risk of
mortality. In contrast, a retrospective study among 1385
elderly individuals > 75 years old from Shanghai, China
found tooth loss was the potential predictors of mortal-
ity [35]. Compared to elder population, total tooth loss
at a younger age is more likely to represent cumulative
exposure to adverse oral and overall health status, and/
or lifetime stressors [36], where the effect of edentulism
on mortality is maximized. Our findings suggest that the
provision of routine dental care and other dental public
health interventions might lead to reductions in early
death.
Our findings demonstrated a consistent association
between edentulism and sarcopenia in both community-
dwelling middle-aged and older populations, suggesting
that the association between edentulism with declining
muscle strength and muscle mass over time is robust.
However, there is emerging evidence that tooth loss is
associated with grip strength and sarcopenia, and most
of these studies are observational and cross-sectional
[37–39]. The predictive value of tooth loss on future sar-
copenia in older adults are still unknown. Our findings
help address this gap illustrating that complete edentu-
lism independently predicts declining grip strength and
muscle mass over time among participants aged 45 years
or older. Our findings suggest that, in addition to health
factors, oral health indicators are important consider-
ations in determining sarcopenia risk status and preven-
tion strategies in the elderly population.
Li et al. BMC Oral Health (2023) 23:333
Fig. 2 Weibull random-intercept survival regression models for survival
and sarcopenia by edentulism groups during Wave 2 to Wave 4
The present study found that the self-reported edentu-
lism in adults aged 45 and above is 15.4%, which is higher
than previous studies [12, 39]. According to the World
Health Organization Study on Global AGEing and Adult
Health (SAGE), the prevalence of edentulism in Chinese
adults aged 50 years and over is 8.9% [23]. Data from the
4th National Oral Health Epidemiology Survey in China
found the prevalence of edentulism aged 65–74 years was
4.42%. According to the study of Khazaei et al. [40]. The
rate of edentulism in developed countries shows a steady
downward trend [41, 42], but in developing countries,
the situation is quite different. Professional dental care
services are not widespread in China, and many dental
treatment programs are not covered by medicare and
are often unaffordable for many, posing a serious public
health challenge for policymakers. Our study will provide
a novel perspective for the formulation of public health
policy. The results of the present study suggest that epi-
demiological studies of edentulous loss and its potential
later burden will be of great significance for clinical treat-
ment planning and later strategy development, as well
as for the assessment of public health needs and service
planning. The data will also have an impact on practical
Page 8 of 10
actions that include oral health to stimulate systemically
health and achieve the major goals of oral health in soci-
ety [43].
There are also limitations to our research. First of all,
because what we are analyzing is secondary data, we can
only choose indicators from the CHARLES question-
naire. Self-reported edentulous loss may be affected by
recall bias. In addition, the queue records the minimum
data related to the use of dentures, so we cannot inves-
tigate the potential modification effects of the observed
associations. Collecting information related to oral
health status progression and other related health out-
comes, such as dentition defects, periodontal disease, use
of dentures, oral health history, and masticatory func-
tion, should be the focus of future edentulous research.
Second, the evaluation of edentulism, cognitive decline
and mortality in this study was followed up for 6 years.
Thus, additional follow-up is necessary to better exam-
ine the associations between edentulism and multiple
health outcomes. Third, the data for most chronic con-
ditions were self-reported and the prevalence of some
chronic conditions were low. Therefore, there might have
been insufficient power to detect a significant differ-
ence. Fourth, considering the exact time of death was not
recorded, the incidence of mortality may be undermined
by absence of precise time of death. Finally, despite the
more comprehensive approach to addressing issues of
confounding compared with prior studies, residual con-
founding from unknown or unmeasured factors still
remains possible.
Conclusions
In conclusion, in this large nationwide cohort study repre-
senting the Chinese mid-adulthood and older population,
edentulism is associated with a higher risk of cognitive
decline, sarcopenia and all-cause mortality, independent
of a wide range of sociodemographic, health, and behav-
ioural confounders. These findings could have impor-
tant clinical and public health implications, as tooth loss
is a quick and reproducible measurement that could be
used in clinical practice for identifying persons at risk of
accelerated aging and shortened longevity, and who may
benefit most from intervention if causality is established.
Public policy and health-care system strategies aimed at
oral health promotion and disease prevention, as well as
increasing access to oral health services for older adults,
are important overarching goals that will improve tooth
retention, thereby decreasing disability and potentially
increasing longevity.
Abbreviations
CHARLS China Health and Retirement Longitudinal Study
TICS Telephone Interview of Cognitive Status
AWGS Asian Working Group for Sarcopenia
ASM Appendicular Skeletal Muscle Mass
Li et al. BMC Oral Health (2023) 23:333
DXA Dual X-ray Absorptiometry
HR Hazard ratio
CI Confidence interval
SD Standard Deviation
BMI Body Mass Index
BDNF Brain-derived Neurotrophic Factor
TrkB Tyrosine Kinase receptor B
AKT1 v-akt murine thymoma viral oncogene homolog 1
NR2B N-methyl-D-aspartate receptor subunit 2B
SAGE Study on Global AGEing and Adult Health.
Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s12903-023-03015-w.
Supplementary Material 1
Acknowledgements
This study used data from the China Health and Retirement Longitudinal
Study (CHARLS). We are grateful to the national development research
institute at Peking University for providing us with the CHARLS data.
Authors’ contributions
All authors have made substantial contributions to conception and design
of the study. YS and XC conceptualized and designed this study. YS and
YL analyzed and interpreted the data. YL, CLH, XZL, YYW and ZQT revised
manuscript for intellectual content. All authors approved the final manuscript
as submitted and agree to be accountable for all aspects of the work.
Funding
This work was supported by Disciplinary Construction Project from School
of Dentistry in Anhui Medical University (for Xin Chen, grant number:
2021kqxKFY04) and 2022 Disciplinary Construction Project from School
of Dentistry in Anhui Medical University (for Xin Chen, grant number:
2022xkfyts01). The funding provides financial support for open-access journal
charges and article processing fees.
Data Availability
Please contact China Health and Retirement Longitudinal Study (CHARLS) for
data requests at http://charls.pku.edu.cn/.
Declarations
Ethics approval and consent to participate
All procedures of the study were performed in accordance with approved
guidelines and regulations. Ethics approval for the study was granted by
the Ethics Review Committee of Peking University. The ethical approval
number for the main household survey, including anthropometrics, was
IRB00001052-11015; the ethical approval number for biomarker collection was
IRB00001052-11014. All the participants provided signed informed consent at
the time of participation.
Consent for publication
Not applicable.
Competing interests
The authors declared no potential conflicts of interest with respect to the
research, authorship, and/or publication of this article.
Received: 21 February 2023 / Accepted: 4 May 2023
Page 9 of 10
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